Violation of onco-surgical principles is associated with survival outcomes in upper tract urothelial carcinomas after radical nephroureterectomy

Authors

  • Ioannis Patras Department of Urology Skåne University Hospital, Malmö, and Institution of Translational Medicine, Lund University, Malmö, Sweden
  • Johan Abrahamsson Department of Urology Skåne University Hospital, Malmö, and Institution of Translational Medicine, Lund University, Malmö, Sweden
  • Axel Gerdtsson Department of Urology Skåne University Hospital, Malmö, and Institution of Translational Medicine, Lund University, Malmö, Sweden
  • Martin Nyberg Department of Urology Skåne University Hospital, Malmö, and Institution of Translational Medicine, Lund University, Malmö, Sweden
  • Ymir Saemundsson Department of Urology Skåne University Hospital, Malmö, and Institution of Translational Medicine, Lund University, Malmö, Sweden
  • Elin Ståhl Department of Urology Skåne University Hospital, Malmö, and Institution of Translational Medicine, Lund University, Malmö, Sweden
  • Anne Sörenby Department of Urology Skåne University Hospital, Malmö, and Institution of Translational Medicine, Lund University, Malmö, Sweden
  • Åsa Warnolf Department of Urology Skåne University Hospital, Malmö, and Institution of Translational Medicine, Lund University, Malmö, Sweden
  • Johannes Bobjer Department of Urology Skåne University Hospital, Malmö, and Institution of Translational Medicine, Lund University, Malmö, Sweden
  • Fredrik Liedberg Department of Urology Skåne University Hospital, Malmö, and Institution of Translational Medicine, Lund University, Malmö, Sweden

DOI:

https://doi.org/10.2340/sju.v59.25973

Keywords:

UTUC, Radical nephroureterectomy

Abstract

Objective: Disease recurrence, particularly intravesical recurrence (IVR) after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC), is common. We investigated whether violations of onco-surgical principles before or during RNU, collectively referred to as surgical violation (SV), were associated with survival outcomes. 

Material and methods: Data from a consecutive series of patients who underwent RNU for UTUC 2001–2012 at Skåne University Hospital Lund/Malmö were collected. Preoperative insertion of a nephrostomy tube, opening the urinary tract during surgery or refraining from excising the distal ureter were considered as SVs. Survival outcomes in patients with and without SV (IVR-free [IVRFS], disease-specific [DSS] and overall survival [OS]) were assessed using multivariate Cox regression analyses (adjusted for tumour stage group, prior or concomitant bladder cancer, comorbidity and preoperative urinary cytology).

Results: Of 150 patients, 47 (31%) were subjected to at least one SV. Overall, SV was not associated with IVRFS (HR 0.81, 95% CI 0.4–1.6) but with worse DSS (HR 1.9, 95% CI 1.03–3.7) and OS (HR 1.9, 95% CI 1.2–3) in multivariable analysis. Additional analyses with a broader definition of SV including also preoperative instrumentation of the upper urinary tract (ureteroscopy and/or double J stenting) showed similar outcomes for DSS (HR 2.1, 95% CI 1.1–4.3).

Conclusion: Worse survival outcomes, despite no difference in IVR, for patients that were subjected to the violation of sound onco-surgical principles before or during RNU for UTUC strengthen the notion that adhering to such principles is a cornerstone in upper tract urothelial cancer surgery.

Downloads

Download data is not yet available.

References

Rouprêt M, Seisen T, Birtle AJ, et al. European Association of Urology guidelines on upper urinary tract urothelial carcinoma: 2023 Update. Eur Urol. 2023;84(1):49–64. https://doi.org/10.1016/j.eururo.2023.03.013 DOI: https://doi.org/10.1016/j.eururo.2023.03.013

Ryoo H, Kim J, Kim T, et al. Effects of complete bladder cuff removal on oncological outcomes following radical nephroureterectomy for upper tract urothelial carcinoma. Cancer Res Treat. 2021;53(3):795–802. https://doi.org/10.4143/crt.2020.919 DOI: https://doi.org/10.4143/crt.2020.919

Nowak Ł, Krajewski W, Chorbińska J, et al. The impact of diagnostic ureteroscopy prior to radical nephroureterectomy on oncological outcomes in patients with upper tract urothelial carcinoma: a comprehensive systematic review and meta-analysis. J Clin Med. 2021;10(18):4197. https://doi.org/10.3390/jcm10184197 DOI: https://doi.org/10.3390/jcm10184197

Marchioni M, Primiceri G, Cindolo L, et al. Impact of diagnostic ureteroscopy on intravesical recurrence in patients undergoing radical nephroureterectomy for upper tract urothelial cancer: a systematic review and meta-analysis. BJU Int. 2017;120(3):313–319. https://doi.org/10.1111/bju.13935 DOI: https://doi.org/10.1111/bju.13935

Schwartzmann I, Pastore AL, Saccà A, et al. Upper urinary tract urothelial carcinoma tumor seeding along percutaneous nephrostomy track: case report and review of the literature. Urol Int. 2017;98(1):115–119. https://doi.org/10.1159/000444808 DOI: https://doi.org/10.1159/000444808

Li YR, Yu KJ, Chang YH, et al. Predictors of intravesical recurrence after radical nephroureterectomy and prognosis in patients with upper tract urothelial carcinoma. Cancer Manag Res. 2020;12:7439–7450. https://doi.org/10.2147/CMAR.S261087 DOI: https://doi.org/10.2147/CMAR.S261087

Liedberg F, Kjellström S, Lind AK, et al. Swedish National Guidelines on Urothelial Carcinoma: 2021 update on non-muscle invasive bladder cancer and upper tract urothelial carcinoma. Scand J Urol. 2022;56(2):137–146. https://doi.org/10.1080/21681805.2022.2041086 DOI: https://doi.org/10.1080/21681805.2022.2041086

Doyle DJ, Hendrix JM, Garmon EH. American Society of Anesthesiologists Classification. StatPearls. Treasure Island, FL: StatPearls Publishing; 2023.

Liedberg F, Hagberg O, Häggström C, et al. Preoperative upper tract invasive diagnostic modalities are associated with intravesical recurrence following surgery for upper tract urothelial carcinoma: a population-based study. PLoS One. 2023;18(2):e0281304. https://doi.org/10.1371/journal.pone.0281304 DOI: https://doi.org/10.1371/journal.pone.0281304

Yonese I, Ito M, Waseda Y, et al. Impact of diagnostic ureteral catheterization on intravesical tumour recurrence following radical nephroureterectomy for upper tract urothelial carcinoma. World J Urol. 2023;41(7):1869–1875. https://doi.org/10.1007/s00345-023-04446-4 DOI: https://doi.org/10.1007/s00345-023-04446-4

Ito A, Shintaku I, Satoh M, et al. Intravesical seeding of upper urinary tract urothelial carcinoma cells during nephroureterectomy: an exploratory analysis from the THPMG trial. Jpn J Clin Oncol. 2013;43(11):1139–1144. https://doi.org/10.1093/jjco/hyt129 DOI: https://doi.org/10.1093/jjco/hyt129

Abel EJ, Fisher MB, Matin SF, et al. Delayed ureterectomy after incomplete nephroureterectomy for upper tract urothelial carcinoma: pathologic findings and outcomes. Int Braz J Urol. 2013;39(6):817–822. https://doi.org/10.1590/S1677-5538.IBJU.2013.06.07 DOI: https://doi.org/10.1590/S1677-5538.IBJU.2013.06.07

Carrion A, Huguet J, García-Cruz E, et al. Intraoperative prognostic factors and atypical patterns of recurrence in patients with upper urinary tract urothelial carcinoma treated with laparoscopic radical nephroureterectomy. Scand J Urol. 2016;50(4):305–312. https://doi.org/10.3109/21681805.2016.1144219 DOI: https://doi.org/10.3109/21681805.2016.1144219

König F, Grossmann NC, Soria F, et al. Pentafecta for radical nephroureterectomy in patients with high-risk upper tract urothelial carcinoma: a proposal for standardization of quality care metrics. Cancers (Basel). 2022;14(7):1781. https://doi.org/10.3390/cancers14071781 DOI: https://doi.org/10.3390/cancers14071781

Nazzani S, Preisser F, Mazzone E, et al. Nephroureterectomy with or without bladder cuff excision for localized urothelial carcinoma of the renal pelvis. Eur Urol Focus. 2020;6(2):298–304. https://doi.org/10.1016/j.euf.2018.09.007 DOI: https://doi.org/10.1016/j.euf.2018.09.007

Liedberg F, Abrahamsson J, Bobjer J, et al. Robot-assisted nephroureterectomy for upper tract urothelial carcinoma-feasibility and complications: a single center experience. Scand J Urol. 2022;56(4):301–307. https://doi.org/10.1080/21681805.2022.2091018 DOI: https://doi.org/10.1080/21681805.2022.2091018

Sui W, Wallis CJD, Luckenbaugh AN, et al. The impact of hospital volume on short-term and long-term outcomes for patients undergoing radical nephroureterectomy for upper tract urothelial carcinoma. Urology. 2021;147:135–142. https://doi.org/10.1016/j.urology.2020.07.062 DOI: https://doi.org/10.1016/j.urology.2020.07.062

König F, Shariat SF, Karakiewicz PI, et al. Quality indicators for the management of high-risk upper tract urothelial carcinoma requiring radical nephroureterectomy. Curr Opin Urol. 2021;31(4):291–296. https://doi.org/10.1097/MOU.0000000000000895 DOI: https://doi.org/10.1097/MOU.0000000000000895

Birtle A, Johnson M, Chester J, et al. Adjuvant chemotherapy in upper tract urothelial carcinoma (the POUT trial): a phase 3, open-label, randomised controlled trial. Lancet. 2020;395(10232):1268–1277. https://doi.org/10.1016/S0140-6736(20)30415-3 DOI: https://doi.org/10.1016/S0140-6736(20)30415-3

Tay LJ, Chatterton K, Colemeadow J, et al. Improving management of upper tract urothelial carcinoma. BJU Int. 2020;126(1):5–6. https://doi.org/10.1111/bju.15068 DOI: https://doi.org/10.1111/bju.15068

Nowak Ł, Krajewski W, Łaszkiewicz J, et al. The impact of surgical waiting time on oncological outcomes in patients with upper tract urothelial carcinoma undergoing radical nephroureterectomy: a systematic review. J Clin Med. 2022;11(14):4007. https://doi.org/10.3390/jcm11144007 DOI: https://doi.org/10.3390/jcm11144007

Abuhasanein S, Jahnson S, Aljabery F, et al. Standardized care pathways for patients with suspected urinary bladder cancer: the Swedish experience. Scand J Urol. 2022;56(3):227–232. https://doi.org/10.1080/21681805.2022.2058605 DOI: https://doi.org/10.1080/21681805.2022.2058605

Yamaguchi N, Morizane S, Yumioka T, et al. Effect of adjuvant systemic chemotherapy on intravesical recurrence after radical nephroureterectomy for upper urinary tract urothelial carcinoma. Anticancer Res. 2023;43(4):1725–1730. https://doi.org/10.21873/anticanres.16325 DOI: https://doi.org/10.21873/anticanres.16325

Downloads

Additional Files

Published

2024-06-19

How to Cite

Patras, I., Abrahamsson, J., Gerdtsson, A., Nyberg, M., Saemundsson, Y., Ståhl, E., Sörenby, A., Warnolf, Åsa, Bobjer, J., & Liedberg, F. (2024). Violation of onco-surgical principles is associated with survival outcomes in upper tract urothelial carcinomas after radical nephroureterectomy. Scandinavian Journal of Urology, 59, 131–136. https://doi.org/10.2340/sju.v59.25973

Issue

Vol. 59 (2024)

Section

Original research article

License

Copyright (c) 2024 Ioannis Patras, Johan Abrahamsson, Axel Gerdtsson, Martin Nyberg, Ymir Saemundsson, Elin Ståhl, Anne Sörenby, Åsa Warnolf, Johannes Bobjer, Fredrik Liedberg

Creative Commons License

This work is licensed under a Creative Commons Attribution 4.0 International License.

Acta Chirurgica Scandinavica Society owns the copyright for all material published until Volume 57 (2023) unless otherwise specified. As from Volume 59 (2024) all published articles, unless otherwise specified, are published under CC-BY licences, allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, with the condition of proper attribution to the original work. 

Crossref
Scopus
Google Scholar
Europe PMC